In Reply.

In reply:

We thank Dr. Herring for his response to our analysis comparing receipt of medication for opioid use disorder (MOUD) among young adults to older adults who experienced a nonfatal opioid overdose in Massachusetts¹. As deaths related to opioids continue to increase, we agree with him that there is a critical need to identify and initiate MOUD with postoverdose survivors. Postoverdose survivors are at the highest risk for subsequent fatal overdose and MOUD consistently shows a protective effect against mortality.

There have been significant shifts in the treatment of patients with opioid withdrawal and overdose in the last few years. Much of that has been driven by Dr. D’Onofrio’s research demonstrating the feasibility and efficacy of ED-initiated buprenorphine². As a result, there are ongoing clinical trials across the United States testing implementation of buprenorphine initiated-ED treatment. To our knowledge, there are no ED-initiated buprenorphine trials targeting adolescents and young adults (youth). Although this paper focused on young adults, our prior work in Massachusetts demonstrated that 8% of individuals under 18 who had a nonfatal overdose received medication treatment in the 12 months following nonfatal overdose³. There are different considerations for youth compared to adults. They often are ambivalent about treatment and may have trusted adults in their lives who can be engaged in the treatment plan. Such youth specific considerations have important implications for how ED-based interventions should be designed for this population.

Driven by an urgent public health need, some ED providers have begun to implement programs to treat patients with buprenorphine after an overdose. For example, Dr. Herring highlights the important work that the California Bridge Project has done working to sustain 24/7 substance use disorder care for patients in all CA health systems. A result of that project has been consideration of buprenorphine initiation after nonfatal overdose standard of care. Furthermore, as Dr. Herring notes, prior to publication of our study there was a clinical guidance based on Dr. Herring and colleague experiences treating individuals with buprenorphine after uncomplicated opioid overdose reversed by naloxone⁴. They provide an algorithm that emergency departments can follow and provide three case examples to demonstrate their success. Importantly, there is the risk of precipitated withdrawal. Although this has not been common in their experience, providers should be prepared to address it and be able to counsel patients on the potential risks in addition to the benefits.

There have been other examples of case studies that have changed the standard of care such as treating patients on buprenorphine with full agonists for pain and continuing buprenorphine in the pre and post-operative settings⁵. It is likely that treatment after an overdose will follow this pattern. We agree that there is a strong rationale for providing buprenorphine after an overdose and applaud efforts to accelerate evaluation and research in this area. Furthermore, given the low receipt of medication treatment and youth specific interventions, we think that there is a compelling need for randomized controlled trials to test youth focused ED-initiated buprenorphine and engagement in care.